Overcoming Challenges to Value-Based Care Implementation: Grant Andres

While the concept of value-based care has largely been embraced in the oncology setting, delivering the best treatments for each patient while meeting the cost and quality measurement standards set in models such as the Enhancing Oncology Model (EOM) can be a challenge.

Grant Andres, BSc, DC, BSN, MSN-RN, Arizona Oncology

In an interview with The American Journal of Managed Care^® (AJMC), Grant Andres, BSc, DC, BSN, MSN-RN, senior director of clinical operations at Arizona Oncology, discussed the nuances of successfully implementing value-based care initiatives across a large organization.

This interview has been lightly edited for clarity.

AJMC: What are some challenges in implementing value-based care in a large network of practices, and how has Arizona Oncology addressed them?

Andres: The diversity within our organization would be the biggest challenge. We have geographical diversity, we have specialty diversity, and all of those things bring with them perspectives that vary significantly. A simple example would be the metrics that we may need to capture for a particular program. One specialty just had an immense problem with capturing the metrics because they just weren't a fit for their style of practice. We had to just figure out how we were going to approach that problem, and that's an example of the diversity within the organization. We currently have 3 different electronic health records that we use, which makes it incredibly challenging, as well. The workflows for some of them are much easier than for others.

So those would be some of the big challenges, and the approach to moving beyond those challenges is simply trying to be very strategic about what your easy victories in the organization are—and of the more challenging ones, which ones are absolutely essential to address and which may be less essential? It's a constant prioritization of not who's making the most noise, but where the biggest opportunities exist. We’re working with a number of programs, and sometimes we'll have somebody that kind of wants to go down a rabbit hole in a particular direction. I feel like it's my job to say, “Well, hold on, strategically speaking, we've got to stay focused on the prize because that's today's prize,” right? The EOM is here, it's now, and we have to be focused on those workflows. For me, my job is to keep people aligned and moving in reasonably the same direction.

AJMC: How has Arizona Oncology begun to implement the new social determinants of health screening requirements posed by the EOM?

Andres: It's definitely a unique slant for that program, and it's a reflection of the goals that CMS and CMMI [Center for Medicare and Medicaid Innovation] have established for now, and maybe the future—time will tell. Fortunately, we have been working with an application that that has really supported us in that area. We have multiple assessment tools using a tablet, and we try to get a tablet into a patient's hands approximately every 3 months. When we give them that tablet, it's going to initially use the NCCN [National Comprehensive Cancer Network] distress screening and problem list tool, and then it's going to follow it up with a PHQ-2 [Patient Health Questionnaire-2] depression screening. If that PHQ-2 is positive, it's going to reflect directly into a PHQ-9, as well. So we cover distress screening and depression screening, and the distress screening tool is one of the recognized, valid tools that CMS has put on their list of acceptable tools.

Being able to do those assessments fairly efficiently on tablets has been good, but yet at the same time, quite challenging because our patients tend to be of an older demographic, and they do not all love the idea of technology encroaching into the patient relationships. There's a lot of communication processes that we have to build out to have our team recognize the value associated with those programs, so that they can be effective at delivering them.

For anybody that's had a tablet in their hand more than 3 or 4 times, it seems like it's really easy, but let me tell you, there's many different things that can go wrong as that process evolves. So, it's been a lot of work, but I think it's good work. The other challenge that goes along with that is that when we're serving the whole patient, it's a lot more work than just diagnosis and treatment. The additional resources demanded to support recognizing and trying to resolve some of the additional needs that patients have is a high resource demand. It’s things that our physician leadership may not be accustomed to having to resource for, so it’s just a little bit of a different structure day to day in the practice.

AJMC: What proactive care strategies have been most successful in providing patient-centered, value-minded care while reducing resource use?

Andres: We talked about the distress screen, we talked about the depression screen, and I will say that, our navigation team generally takes the first pass at the distress screens that are positive, and our social work team takes the first pass at the depression screens that are positive. Before we did it on tablet, we didn't have nearly the level of success, and I believe that the reason for that is because the tablet puts it onto a work board, so all of the centralized teams have access to that work board and can take action.

I remember early in the process, my team’s telling me, ‘We just found somebody who expressed on their distress screen that they're having trouble eating.’ The first thing that comes to people's mind is that these people are having trouble affording their food, but that wasn't the case at all. They had been under a lengthy period of chemoradiation for a head and neck cancer, and they just could not swallow. Somehow, the system is less than perfect, and they have not been sent for a PEG [percutaneous endoscopic gastrostomy] tube, and we got them set for a PEG tube. It ended up being a nice success story for our team. You know, the systems in place for diagnosis and treatment have their weaknesses, being able to find other touch points—really, I think that's almost what it boils down to, is finding thoughtful touch points with our patients so that they have the opportunity to tell us they're having problems.

AJMC: Can you speak to the role of collaboration between primary care providers and oncologists to improve care and manage costs for patients with cancer?

Andres: With the advent of things like the NCCN distress screen and the depression screening—and the other tools that that we use to identify high-risk patients—I think most medical oncologists or radiation oncologists don't want to manage the patient's back pain, and they don't want to manage the respiratory tract infection that comes up and all of these other things. So, I think that the additional touch points help us to identify not only oncology-related challenges, but other health challenges that patients are having. We have a ton of patients that don't have a primary care provider, and we feel like we have a responsibility to try and recognize when they need one and try to facilitate that connection with someone in their community.